A new study published in JAMA by a team from the Schneider Institutes for Health Policy and Research reveals that people with disabilities are less likely to be prescribed medications that treat opioid use disorder, such as like buprenorphine or methadone.
The study is a product of the NIDILRR-funded INROADS project (Intersecting Research on Opioid Misuse, Addiction, and Disability Services), a joint research program between the Institute for Behavioral Health (IBH) and the Lurie Institute for Disability Policy and a NIDA-funded study of OUD in Washington State. Two of the study’s authors, Professor and Associate Dean for Research Cindy Parks Thomas, PhD’00, and Professor Sharon Reif, PhD’02, discussed their findings and policy recommendations with Heller Communications.
Tell us about your findings. How does treatment for opioid use disorder differ for people with disabilities?
In theory, treatment for opioid use disorder (OUD) for people with disabilities should be the same as for people without disabilities. We looked at the quality of OUD treatment for people with disabilities (physical, sensory, developmental and cognitive) and without those disabilities, who are covered by Medicaid, over the years 2016-2019. We measured quality of care using two widely recognized measures: 1) use of medications to treat opioid use disorder, which should be a cornerstone of treatment; and 2) continuity of treatment for those on medications to treat OUD.
We found that people with disabilities who were diagnosed with OUD were 40% less likely to be on medications, and those who were on appropriate medications were 13% less likely to remain on them for six months, a recommended treatment regimen.
What does opioid use disorder treatment look like in the U.S. today?
OUD remains a serious epidemic. Over 100,000 individuals die from drug overdoses each year in the United States, with 70% related to opioids. We have appropriate medications to treat the disease, including buprenorphine, methadone, and naltrexone, but they are underutilized in general despite significant improvements in outcomes. Access to treatment is also inadequate, and in certain areas few providers are available. There remains a stigma associated with OUD, both among providers and in society.
What do these treatment differences suggest about health care inequities among people with disabilities?
These differences cannot be explained by clinical factors. Over 30 years after the passage of the 1990 Americans with Disabilities Act (ADA), people with disabilities experience barriers to care in many ways.
As we note in our paper, and demonstrated by other researchers, people with disabilities may have limited access to treatment due to physical barriers, or providers who may be unfamiliar with the sometimes complex needs of people with disabilities. One study found that fewer than half of U.S. physicians felt very confident about their ability to provide the same quality care to people with disabilities as others, and another indicated that only half strongly welcomed people with disabilities in their practice.
Both disability and OUD are stigmatized conditions – within health care and within society. People who are multiply stigmatized may be less likely to access care and less likely to get adequate care. These disparities can and should be addressed to improve care for people with both disability and OUD.
Can you speculate as to why people with disabilities are at increased risk of OUD and yet have decreased rates of treatment?
People with disabilities have increased risk factors for OUD, including the presence of pain and use of pain medications, co-occurring psychological conditions, and adverse social determinants of health. However, not everyone with disabilities has these increased risks, and many people without disabilities do.
This nexus of risk factors highlights the need to screen for and identify opioid problems and get people with OUD into care. However, the intersecting stigmas of OUD and disabilities creates a strong barrier to equitable treatment. Moreover, OUD treatment may not be accessible for people with disabilities. There may be physical barriers to access, as well as a lack of materials adapted for people with specific communication or cognitive needs. As well, practitioners may be reluctant to treat patients who are experiencing pain with medications for OUD or who are seen as “too complex.”
What policy changes do you recommend to potentially correct this disparity?
Several approaches are important, which incorporate provider training to decrease stigma, and enforcement of physical and other accommodations for people with disabilities. Providers who treat people with disabilities should be trained to screen for OUD, and be trained to be comfortable with treatment or referral as needed. Accommodations such that prescribed under the ADA. Studies show that currently not all providers comply with the ADA.
What additional research is needed to better understand – and correct – this issue?
Of course, it is important to disseminate research, including our current study, to spark discussion among the provider, policy, and advocacy communities to consider solutions.
Additional research might look at the types of patients and providers that are most likely to receive poorer-quality care, in order to target policies that would mitigate disparities. Our research was in a state Medicaid program, which includes a large population of people with disabilities, but we would like to see how these data compare to people with commercial or workplace-covered insurance, who may have additional resources at hand. We would want to look at additional measures of quality and patient outcome to identify additional levers that could be addressed, such as transitioning patients from inpatient or residential care to follow-up in the community. Finally, qualitative research with people in the disability community is essential to understand how they perceive the barriers and potential solutions specific to OUD.